The analysis has national implications given the state’s size as well as the nationwide trend of employers to shift more costs onto workers via higher copayments and deductibles–the very cost-sharing strategies people don’t understand. Plans offered under the Affordable Care Act are also shifting costs onto policyholders.

Ana Granado and her daughter Andreia Walker look over healthcare paperwork at their home in Charlotte, N.C., Feb. 10, 2016. Granado had health insurance through Affordable Care Act and was undergoing treatment for breast cancer when she found out her premiums were going up more than six-fold. (AP Photo/Chuck Burton)

“We are going to see this everywhere in the country because if you look at just the insured people in our survey, there is still a substantial lack of understanding in using and understanding these terms,” Vivian Ho, chair in health economics at Rice’s Baker Institute for Public Policy, which funded the study along with the Episcopal Health Foundation, said in an interview.

The report also comes during a period of unprecedented change in healthcare as millions more Americans who have obtained coverage under the health law see copayments and deductibles–what they pay out of pocket to get treatment–rise even as they shop for a better deal on public exchanges. To get a lower premium, which is what they pay monthly to the insurer, they often have to endure a higher deductible or other out-of-pocket costs.

“The challenging thing about the (ACA) marketplaces is that they are offering skinnier plans relative to what employers provide,” Ho said. “If you don’t know what your deductible is or what your maximum out-of-pocket costs are, you are going to be disappointed when you go to use your insurance.”

The study included people that had insurance as well as those uninsured. Thus authors say it is an indication employers aren’t doing a good job educating their workers about health benefits.